Breast Feeding The Preterm
The Right Must Be
Done Right
Dr Eisa Sayed Ahmad
Neonatologist
IBCLC
Breastfeeding is one of the most effective
ways to ensure child health and survival.
If every child was breastfed within an hour
of birth, given only breast milk for their
first six months of life, and continued
breastfeeding up to the age of two years,
about 800,000 child lives would be saved
every year.
WHO
Breastfeeding Recommendations
• “Exclusive breastfeeding is the ideal nutrition source and
sufficient to support optimal growth and development for the
first six months of life.”
• The American Academy of Pediatrics recommends
breastfeeding continue for at least the first 12 months.
(American Academy of Pediatrics Position Statement. Breast Feeding and the Use of Human Milk. Pediatrics 1997;100:10351039.)
HOLY QURAN
GOALS OF NUTRITION
• Defining and achieving a standard of short-term growth
• Meeting the unique nutritional needs of prematurity
• Preventing feeding-related morbidities
• Optimizing long term outcome
Preventing Feeding-Related Morbidities in Premature Infants
• Necrotizing enterocolitis
• Osteopenia of prematurity
• Vitamin and mineral deficiencies
• Feeding intolerance
• Prolonged TPN and related cholestasis
• Nosocomial infections
• Prolonged hospitalization
• Lack of full physical and intellectual potential
Effect of HM on morbidity & hospital stay
BWT 1000g ,GA <30 WK , *P<0.01 ,
**P< 0 .07,
***P<0.05
pediatrics
Clinical Benefits of Human Milk for Preterm Infants
• Improve Host Defense – reduced infections
• Promote GI Development: Establish normal gut flora,
• 64% decrease in GI infections
• Enhance lung maturation:72% decrease in RTI
• Provide Special Nutritional Needs :Better weight gain
• Improve Neurodevelopmental Outcome
• Support Physically & Psychologically Healthier Mother
• Shorter hospital stay
• infant mortality could be reduced by 21%
• Economic & Environment
Feeding Strategies
Total parenteral nutrition
Mother’s own milk (with appropriate fortification)
Donor human milk (with appropriate fortification)
Premature infant formulas
• Compared to the mothers milk of a full-term infant, The milk produced
by the mother of a PT infant in the first four weeks after delivery contains
a higher concentration of:
• nitrogen
• proteins with immunological functions
• total lipids, medium-chain fatty acids
• vitamins A, D and E
• calcium, sodium and energy
• A good strategy that results in increased weight gain among PT infants is
the one that offer hindmilk, which contains up to three times more fat
than foremilk. Which result in an average increase in weight of 15 g a day
Extremely-Low-Birthweight Infants Grow Poorly
Average body weight compared to intrauterine growth
Ehrenkranz RA, Younes N, Lemons JA, et al. Longitudinal growth of hospitalized very low birth weight infants. Pediatrics. 1999;104(2 Pt 1):280–289
Summary Human
of differences
between
milks
milk
Animal milks
Infant formula
Protein
correct amount, easy too much, difficult to
to digest
digest
partly corrected
Fat
enough essential fatty lacks essential fatty
acids, lipase to digest acids, no lipase
no lipase
Water
enough
extra needed
may need extra
Anti-infective
properties
present
absent
absent
Colostrum
Property
Importance
Antibody
protects against infection and allergy
Many white cells
protects against infection
Purgative
clears meconium; helps prevent jaundice
Growth factors
helps intestine mature; prevents allergy,
intolerance
Vitamin-A
reduces severity of some infection (such as
measles and diarrhoea); prevents vitamin Arelated eye diseases
Mother's milk represents a foundational step in the
proper development of newborn immunity
Host Defense:
• Cellular elements
Lymphocytes, PMN&
• Immunomodulatory Prolactin
• Macrophages
• Immunoglobulins & other direct
anti-infective factors
• Cytokines
• Cortisol, thyroxine, insulin
• IgA, Secretory IgA Lactoferrin
Lysozyme
Casein
• & growth factors
• Interleukins
• Interferon
• TNF&TGF
• Mucin
Anti-inflammatory factors
• Other bioactive factors
Oligosaccharides
FFA
Nucleotides
• Vitamin A,C,E
Catalase
Glutathione peroxidase PAF
• acetyl hydrolase
Prostaglandins
• Glutamine, Taurine
Lactoferrin – Milk’s “White Gold” a Natural Immune Enhancer
• major Iron binding protein in the breast milk , bind to
a specific lactoferrin receptor in the small intestine
facilitating the uptake of both lactoferrin and iron
• anti-bacterial, anti-viral, and anti-fungal, and anticarcinogenic properties
• enhance bone growth and formation
• In the gut lumen : has bacteriostatic and bactericidal
activities
• Clinical studies : lactoferrin can reduce respiratory
disease in Term infants and sepsis in preterm infants
Alpha-lactoalbumin
• alpha-Lactalbumin is the major protein in
breast milk (20-25% of total protein)
• have antibacterial and immunostimulatory
properties ,anti-infective activity and
enhances apoptosis
• it participates in lactose synthesis
• facilitate the absorption of essential
minerals
• provides a well-balanced supply of essential
amino acids to the growing infant
HAMLET
• Human Alpha Lactalbumin Made Lethal To
Tumor cells
• It’s a protein lipid complex composed of
tow major human milk constituents
• Helmet induces Apoptosis in tumor cells
but leaves fully differentiated cells unaffected
• the results identify HAMLET as a new
candidate in cancer therapy
Milk fat globulin membrane(MFGM)
• is the membrane surrounding lipid droplets during
their secretion in the alveolar lumen of the
lactating mammary gland
• contains many bioactive components
• Attached to the MFGM is a variety of proteins. MFGM contains over
100 different proteins.
• These proteins have been shown to have positive effects on both
neurodevelopment and defense against infections. As it is involved
in various cellular processes and defense mechanisms in the
newborn
Infections
• human milk compared with formula has a protective
effect to the onset of infections in preterm VLBW
• (systematic review three randomized controlled trials and six observational studies regarding the relationship
between nutrition, infection and human milk) Archives of Childhood Disease
the risk of late onset sepsis is significantly reduced by
an early enteral feeding with human milk
(a large prospective study about extremely low birth weight infants or infants with less t han 28 weeks
gestational age at birth) Pediatrics
Percent with diarrhoea
Percentage of babies bottle-fed and breastfed for the first 13 weeks
that had diarrheal illness at various weeks of age during the first
year, Scotland
25
20
22.3
19.5
19.1
12.9
15
10
5
22.4
11.9
7.1
3.6
0
0-13
14-26
27-39
40-52
Incidence of diarrhoeal illness by age in weeks
Bottle-fed
Breastfed
Adapted from: Howie PW, Forsyth JS, Ogston SA, Clark A, Florey CV. Protective effect
of breastfeeding against infection. Br Med J, 1990, 300: 11-15.
Percentage of babies bottle-fed and breastfed for the first 13 weeks
that had respiratory illness at various weeks of age during the first
Percent with respiratory
illness
year, Scotland
54.1
60
50
40
30
47.1
38.9
45.5
42.4
40
36.2
23.1
20
10
0
0-13
14-26
27-39
40-52
Incidence of respiratory illness by age in weeks
Bottle-fed
Breastfed
Adapted from: Howie PW, Forsyth JS, Ogston SA, Clark A, Florey CV. Protective effect of
breastfeeding against infection. Br Med J, 1990, 300: 11-15.
Transparency 2.23
Percent with acute otitis
media
Frequency of acute otitis media in relation
to feeding pattern and age, Sweden
20
20
14
15
10
5
5
13
7
6
4
1
0
1-3
4-7
8-12
months
breastfed
mixed fed
weaned
Adapted from: Aniansson G, Alm B, Andersson B, Hakansson A et al. A prospective coherent
study on breast-feeding and otitis media in Swedish infants. Pediat Infect Dis J, 1994, 13: 183188.
Breastfeeding decreases the risk of allergic disorders
– a prospective birth cohort study
Type of feeding
Asthma
Atopic
Allergic
dermatitis rhinitis
Children exclusively
breastfed 4 months or
more
7.7%
24%
6.5%
Children breastfed for
a shorter period
12%
27%
9%
Breastfeeding reduces the risk of chronic disease
Adapted from Kull I. et al. Breastfeeding and allergic diseases in infants - a prospective birth
cohort study. Archives of Disease in Childhood 2002: 87:478-481.
Infection Rates in High Risk Infants
Necrotizing Enterocolitis (NEC)
• high fatality
• long-term morbidity due to complications
• HM reduces the incidence by 77%.
• outcomes : dose response effect of HM feeding
• a dose of mother’s own milk > 50 ml/kg/d decreases the risk of late-onset
sepsis and NEC compared to < 50 ml/kg/d and for each 10 ml/kg/d increase in
human milk in the diet there is a 5% reduction in hospital readmission rate
• The mechanisms :multifactorial.
• Human milk sIgA, lactoferrin, lysozyme, bile salt-stimulating lipase, growth
factors, and HMOs
Reduced NEC with HM-Based Fortifier
human milk–only diet : significantly reduced risk of NEC, sepsis, and mortality and on
average have 8 days less need for total parental nutrition
oligosaccharides
• oligosaccharides :Originally described as a prebiotic “bifdus
factor” that serves as a metabolic substrate for desired
bacteria and shapes an intestinal microbiota composition
• Human milk contains more then 130 different
oligosaccharides
• The concentration : highest in the colostrum on day 4 of
lactation
• today oligosaccharides are known to be more than just “food
for bugs”: directly act preventing pathogen adhesion to infant
mucosal surfaces, lowering the risk for infections, and
modulate epithelial and immune cell responses
Oligosaccharides
• A recent study :higher concentrations of
Human Milk Oligosaccharides (HMOs) in
preterm compared with term milk
• The different HMOs concentrations in
preterm and term milk : represent a
programmed adaptation of milk
composition to the special needs of the
infants
In the same study
• Lower lactose concentrations in
preterm milk.
• positive effects :lactose contributes
to lower milk osmolality.
• Low levels :lower substrate levels
for the well-known lactase
deficiency that is common among
these newborns
Neurodevelopmental & Cognitive Development
• Many studies: higher cognitive
development, specifically higher IQ
or Bayley score
• Improvement in developmental
achievements
Neurodevelopmental & Cognitive Development
Extremely PT :significantly greater scores
for mental, motor, and behavior ratings
at ages 18 months and 30 months.
high risk preterm for brain injury and
insult, human milk feedings must be a
priority.
Long-term studies at 8 years of age
:intelligence test results, white matter
and total brain volumes are greater 20%
more and improved
neurodevelopmental outcomes
RETINOPATHY OF PREMATURITY
• Omega 3 fatty acids are essential to the normal
development of the retina, especially in VLBW
infants.
• Thus, these lipids, with other antioxidant substances, such as vitamin
E, beta-carotene and taurine, may explain the protection provided
by human milk against retinopathy of prematurity
• the incidence and severity :significantly low in those who were
exclusively breastfed or whose diet consisted of at least 80% of
human milk.
Feeding tolerance
in meta-analysis of data from randomized controlled trials indicated
that feeding with formula milk, compared with donor breast milk (DM), leads
to higher rates of feed intolerance and necrotising enterocolitis in
preterm infants
There are several non-experimental studies indicating that clinical feeding
tolerance is improved, and the attainment of full enteral feeding is made
quicker by a diet of human milk
Oral Care with Human Milk benefits
• (a) powerful antimicrobial agent :coating the
infant’s mouth with milk a front-line defense
• (b) a rich source of cytokines, which absorbed
through the infant’s buccal mucosa, thus positively
impacting the immune system
• (c) a sweet flavoring, provides a positive oral
experience
Human Milk Fortification
• Must fortify human milk to provide adequate energy, protein, minerals and
vitamins for the growing premature infant
• infants who receive a human milk–only diet have a significantly reduced
risk of NEC, sepsis, and mortality and on average have 8 days less need for
total parental nutrition
Human Milk Fortification
• Babies randomized to
receive human milk- based
fortifier had 50% reduction
in medical NEC (p<0.03) and
90% reduction in surgical
NEC (p<0.007) compared to
bovine-based
Conclusion
The role of health care workers, including pediatricians, is
to protect, promote, and support breast-feeding
the importance of nutrition in the early period of life is
now well known, and the term “programming” has been
proposed to emphasize that early nutrition should be
considered not simply in terms of meeting immediate
nutritional needs, but also for its potentially long-lasting or
lifelong biological effects
The target is to achieve growth potential and to ensure
their good health and a normal neurological development
Challenges we face in preterm infants
• Hypotonia
• Coordination
• Rds
• Small oral cavity
• Mother reaction to her baby sickness
• Our support to the mother
• We speak about short term goals and intermediate term and long
term goals
• We try to talk not about the successful breast feeding because the
opposite of this word is failure which is award no mother likes to hear
• Is breast feeding always natural
• We should tell the mother how hard is the breast feeding